A Social Media Intervention for Exercise Motivation and Cardiac Rehabilitation Adherence

March 24, 2020 updated by: Lee Anne Siegmund, The Cleveland Clinic

Feasibility of a Social Media Intervention for Exercise Motivation and Cardiac Rehabilitation Adherence

While cardiac rehabilitation (CR) has been shown to be effective at improving cardiovascular disease (CVD), participation is generally poor. The current feasibility study, will evaluate the impact of a social media intervention on motivation for exercise and adherence to CR sessions. Participants will be randomly assigned to a Facebook™ group or an enhanced education comparison group. The intervention will include access to a private Facebook™ group in which participants will receive weekly educational posts, weekly provider support and have the opportunity to communicate with other cardiac rehabilitation patients. Patients in the comparison group will be given the same educational materials, but these will be supplied in email. Participants will be asked to fill out a pre-post motivational questionnaire and the total number of sessions attended at the end of 3 months will be tallied. This study is grounded in Self-Determination Theory (SDT) and utilizes the Behavioral Regulation in Exercise Questionnaire (BREQ-2), which is based on the SDT.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

There is no research that addresses the use of Facebook as a tool to affect autonomous motivation in cardiac rehabilitation.

The purpose of the current feasibility study is to determine the feasibility of using a Facebook intervention, providing education, peer support and provider support, to affect change in motivation and self-determination for exercise, and adherence to cardiac rehabilitation in patients with CHD during a 12-week Phase II cardiac rehabilitation program. It is hypothesized that:

  1. Scores for motivation for exercise overall will increase for patients exposed to a Facebook intervention and across individual motivational subtypes (regulations) relative to a comparison group who receive educational handouts and emails.
  2. Percentage of cardiac rehabilitation sessions attended will be higher relative to a comparison group who receive educational handouts and emails.
  3. Engagement in the private Facebook group (number of "hits" and "likes") will predict number of cardiac rehabilitation sessions attended and the change in motivation. The feasibility of a larger trial will be based on sample size and participants' engagement in the Facebook group.

Methodology Design This is a prospective, randomized controlled pilot trial to evaluate the feasibility of using a social media intervention to affect change in motivation for exercise and adherence to cardiac rehabilitation.

Setting and Sample:

The setting for this study will be in the outpatient cardiac rehabilitation at the main campus of a large tertiary care center in Northeast Ohio and several satellite facilities in the region. All patients receive an individualized exercise prescription based on functional capacity at intake. Most patients will be able to attend up to 3 sessions per week for a total of 36 sessions.

All patients who are current and regular Facebook users, have qualified for cardiac rehabilitation (diagnosed with CHD), and are entering cardiac rehabilitation at the main campus or one of the regional satellite hospitals of this tertiary care center, will qualify to participate in the study prior to beginning Phase II cardiac rehabilitation. Current Facebook users were chosen . Regular use will be defined as logging onto Facebook at least 2 times in the last month. Inclusion criteria will include both men and women 18 years of age or older and live within 100 miles of the main campus of this tertiary care center. Participants must be able to read and understand English in order to complete the questionnaires: the Psychological Need Satisfaction in Exercise Scale (PNSE) [37] and the Behavioral Regulation in Exercise Questionnaire-3 (BREQ-3). There will be no exclusion based on secondary diagnosis; however, participants must be able to exercise well enough to qualify to take part in cardiac rehabilitation.

Measures:

Change in motivation for exercise, will be measured at baseline and post-intervention using the BREQ-3. The BREQ-3 is a 24 question validated instrument that measures forms of intrinsic and extrinsic regulation of exercise behavior and is based on self-determination theory. Psychometrics were completed for the BREQ-2 by Markland and Tobin. Cronbach's alpha reliabilities were: amotivation = 0.83, external regulation = 0.79, introjected regulation = 0.80, identified regulation = 0.73, and intrinsic regulation = 0.86. The BREQ-3 includes 5 additional questions in addition to those on the BREQ-2 and has a new subscale for integrated regulation [33]. The subscales (regulations) of the BREQ-3 are used to calculate a relative autonomy index (RAI). Each question is answered on a 5 point Likert scale (0-4) and represents one of the regulations. The regulations are weighted then summed to give a single score. The resulting index gives an indication of individual respondent's self-determination for exercise.

The RAI will place individual motivational subtypes or behavioral regulations on the self-determination continuum from amotivated (lacking intention to exercise) to intrinsically motivated (self-determined or autonomously motivated).

The PNSE will be used to assess need satisfaction with exercise. This scale was designed to assess the perception of psychological need satisfaction associated with self-determined motivation for exercise and consists of 18 items on a 6 point Likert scale, with 3 subscales measuring perceived competence, autonomy, and relatedness. The scale showed high internal consistency (Cronbach >0.90) [37].

The percentage of cardiac rehabilitation sessions attended will be measured at the time of cardiac rehabilitation completion or dropout. It will calculated by dividing the number of sessions attended in a 3 month period of time by the total number of sessions allowed by insurance, and multiplying by 100.

Facebook engagement, will be assessed by measuring the number of "likes" by individuals on the private Facebook group. "Likes" (the number of times a participant clicks "like" on any of the Facebook posts) will be counted and, along with "hits" will be used to examine the association between engagement in the intervention, and cardiac rehabilitation adherence and change in motivation. A post-intervention questionnaire will be given to determine number of "hits". The participants will be asked to circle the number of times they accessed the private Facebook group per week: 0, 1-5, 6-10, 11-15 or > 15 times. The questionnaire will also be used to collect qualitative data on participants' perceptions of the intervention, including whether they felt supported in their care, more in touch with providers, whether or not they chatted with other Facebook members and if the Facebook group affected their exercise behaviors. The questionnaire will use a Likert scale (1, "not at all"-5, "quite a bit") for all questions and a section for comments.

Patient characteristics will include key demographic variables (age, gender, race, employment, distance to cardiac rehabilitation, socioeconomic status), engagement (number of "hits" and "likes"), and key clinical variables (functional capacity as measured in METS,cardiac rehabilitation indication, hypertension, diabetes, hyperlipidemia and waist circumference), which will be obtained from the electronic medical record.

Data Collection Procedures:

Volunteers will be recruited from the main campus or regional satellite hospitals of this tertiary care center during their inpatient stay, at the intake visit for cardiac rehabilitation at the main campus and satellite facilities in the region, or via phone call after discharge and up to the first cardiac rehabilitation session. Volunteers will be screened for Facebook use and interest in the study, then an email link will be sent which will include an information sheet. The Facebook group will be private in the sense that those not in the group will not be able to see the content. Participants will be given a baseline BREQ-3 questionnaire and PNSE scale. Participants will then be randomized to Facebook versus comparison groups using blocked randomization.

Intervention. The Facebook intervention will include peer support, education, provider support. These interventions are designed to minimize pressure, offer choices, and allow for peer interaction, and positive feedback in order to provide support for competence, autonomy and relatedness. Competence will be supported with use of educational posts. Autonomy support will come from provider posts. Relatedness will be supported by peer interaction and engagement in the Facebook group.

Educational posts will cover topics that will encourage participants to practice preventive heart care. The educational portion of the intervention is designed to offer clear information and structure, thus supporting competence. The posts may be in the form of text, video and/or pictures and will include materials from the hospital's health library, the American Heart Association and the Center for Disease Control.

Provider posts will include topics such as motivational quotes, encouragement, reminders to exercise independently, and reminders to contact providers with questions. These postings are designed to promote a sense of choice and help participants feel that providers see them as having a unique frame of reference thus being autonomy-supportive. Providers will be nurses on the research team, exercise physiologists nurse practitioners and physicians. Provider support will also include links to provider health chats, in which patients can chat online with providers at set dates and times.

Peer interaction on Facebook will be as frequently as the participant chooses and will be monitored daily by the research team. Engagement in Facebook is designed to offer an opportunity for social inclusion and a sense of involvement.

The comparison group will receive the same educational and provider support materials as the Facebook group but will receive it via email. Both groups will have the opportunity for weekly education classes and typical peer interactions.

Upon cardiac rehabilitation completion or dropout, post-data will be collected. It is anticipated that this pilot will take up to one year and will be completed when 30 participants for each group have been obtained.

Data Analysis Statistical Methods. This is a feasibility study and the sample size obtained will determine if the study is appropriately powered to detect the desired effect size. Patient characteristics will be summarized group using frequencies and percentages for categorical factors, and means and standard deviations for continuous measures. In order to examine the primary outcome, differences in change in motivation between groups, overall motivation using the RAI from the BREQ-3 will be evaluated using analysis of covariance (ANCOVA) models. Mean differences with 95% confidence intervals for group differences will be presented. Multivariate analysis of variance models will be used to evaluate differences in the change across individual motivation subtypes (regulations), using the BREQ-3, between groups overall. If significant, separate ANCOVA models for each subtype will be fit. Similar models will be used to compare changes in needs satisfaction scores, overall and separately among the three subscales, between groups. Two-sample t-tests will be used to compare number of sessions completed. As a secondary analysis, the relationships between patient characteristics, "hits" and "likes", and the outcome variables RAI change, number of sessions, and needs satisfaction change will be examined using t-tests and Pearson correlations. The correlation between changes in RAI and needs satisfaction will also be evaluated. Analyses will be performed using SAS software (version 9.4; Cary, NC). An overall significance level of 0.05 will be assumed for all tests.

Sample Size. The investigators plan to enroll 30 patients in each group. In the first 9 months of 2016, cardiac rehabilitation at the main campus of this tertiary care center had approximately 170 patient intakes. It is assumed that there will be a similar number of patient intakes for a 9 month period in 2017. Based on Facebook participation rates for those over age 50 [21] and the high participation rates in previous research projects in this facility's cardiac rehabilitation, it is estimated that 40% may meet eligibility requirements and agree to participate. Allowing for use of the first 8 participants to establish the Facebook group, the estimated sample size would then be 60 total participants for randomization to study group who can then be included in analysis. With this sample size, there will be 86% power to detect large effect sizes (d=0.8) for our study outcomes [40]. The primary aim of this sample size determination is to evaluate whether the proposed intervention is feasible, and to estimate the differences that might exist so that a larger trial that would have adequate power to detect smaller differences could be designed based on what was learned in this pilot study. The sample size of 30 per group was chosen primarily to facilitate a large intervention group, since the value of the intervention is predicated upon interaction among the participants.

Study Type

Interventional

Enrollment (Actual)

22

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Ohio
      • Cleveland, Ohio, United States, 44195
        • The Cleveland Clinic

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • All male and female patients who are current and regular Facebook™ users, 18 years of age or older, have qualified for cardiac rehabilitation (diagnosed with cardiovascular disease), and are entering cardiac rehabilitation at the Main Campus of the Cleveland Clinic, will qualify for the study.

Exclusion Criteria:

  • Participants must be able to exercise to the extent that they can take part in cardiac rehabilitation, must live within 100 miles and must be able to read and speak English.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Facebook group
The Facebook group will receive peer support, education and provider support via social media.
Behavioral: Facebook
  1. Volunteers will be recruited during inpatient stay, or via phone call or in person after discharge and prior to beginning cardiac rehabilitation.
  2. Participants will be given a baseline BREQ-3 survey and a PNSE scale.
  3. Patients will be randomized to Facebook™ versus comparison groups using a blocked randomization.

  4. The Facebook™ intervention will include peer support, education, provider support and text message prompts when new posts are added.

    1. Educational posts will cover topics that will cover healthcare information.
    2. Provider support will be posted much like the educational posts.
  5. The data collection for this study will take place prior to beginning cardiac rehabilitation, at which time the participants will receive the BREQ-3 and PNSE surveys either in person or via email link.
  6. Post-testing will include a BREQ-3 and PNSE surveys and count of the number of sessions completed in a 3 month period of time.
Active Comparator: Comparison group
The comparison group will receive the same educational materials as the Facebook™ group but will receive it in handout form, or via email if the patient misses cardiac rehabilitation on a particular week.
Behavioral: Facebook
  1. Volunteers will be recruited during inpatient stay, or via phone call or in person after discharge and prior to beginning cardiac rehabilitation.
  2. Participants will be given a baseline BREQ-3 survey and a PNSE scale.
  3. Patients will be randomized to Facebook™ versus comparison groups using a blocked randomization.

  4. The Facebook™ intervention will include peer support, education, provider support and text message prompts when new posts are added.

    1. Educational posts will cover topics that will cover healthcare information.
    2. Provider support will be posted much like the educational posts.
  5. The data collection for this study will take place prior to beginning cardiac rehabilitation, at which time the participants will receive the BREQ-3 and PNSE surveys either in person or via email link.
  6. Post-testing will include a BREQ-3 and PNSE surveys and count of the number of sessions completed in a 3 month period of time.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Motivation
Time Frame: 12 weeks
Measured using Behavioral Regulation in Exercise Questionnaire-3 (BREQ-3)
12 weeks
Needs Satisfaction
Time Frame: 12 weeks
Psychological Needs Satisfaction in Exercise Scale (PNSE)
12 weeks

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Adherence
Time Frame: 12 weeks
Number of cardiac rehabilitation sessions attended
12 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

The Cleveland Clinic

Collaborators

Sigma Theta Tau International Honor Society of Nursing

Investigators

  • Principal Investigator: Lee A Siegmund, PhD, The Cleveland Clinic

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 27, 2017

Primary Completion (Actual)

February 28, 2019

Study Completion (Actual)

March 1, 2019

Study Registration Dates

First Submitted

November 21, 2016

First Submitted That Met QC Criteria

November 22, 2016

First Posted (Estimate)

November 23, 2016

Study Record Updates

Last Update Posted (Actual)

March 27, 2020

Last Update Submitted That Met QC Criteria

March 24, 2020

Last Verified

March 1, 2020

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 16-1456

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

Facebook log in's and demographic variables as well as survey responses will be shared with the research team. This information will be shared using encrypted flash drives and computers and emails will be confidential. All responses from participants on the Facebook™ group will be assigned a number and all other identifying information will be removed for data analysis. Any data on paper will be kept in the PI's locked office in a locked filing cabinet. All electronic data will be stored on the PI's computer which requires password entry and in a folder accessible only to the PI and the research team.

IPD Sharing Time Frame

Starting 2/27/17 until after manuscript submission

IPD Sharing Access Criteria

With permission of PI

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL
  • SAP

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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